SAFETOTS
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A talk by Torsten Lauritsen at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine. All available content from SSAI2017: https://scanfoam.org/ssai2017/ Delivered in collaboration between scanFOAM, SSAI & SFAI.
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SAFETOTS
- 1. Rigshospitalet SAFETOTS Torsten Lauritsen Department of Anaesthesia The Juliane Marie Centre Rigshospitalet, Copenhagen Anæstesi- og Operationsklinikken, Juliane Marie Center 1
- 2. Rigshospitalet COI SAFETOTS Torsten Lauritsen 2 • None
- 3. Rigshospitalet Content SAFETOTS Torsten Lauritsen 3 • Background • Organisation – The 5 W • Clinical - The 10 N
- 4. Rigshospitalet Vision SAFETOTS Torsten Lauritsen 4 • All paediatric patients receive anaesthetic service by the highest possible standard • Paediatric anaesthesia is only given by trained paediatric anaesthetists
- 6. Rigshospitalet FDA: Anaesthesia is dangerous to the imature brain SAFETOTS Torsten Lauritsen 6
- 7. Rigshospitalet FDA: Information to parents SAFETOTS Torsten Lauritsen 7
- 9. Rigshospitalet SAFETOTS Torsten Lauritsen 9 SmartTots (Strategies for Mitigating Anesthesia-Related neuroToxicity in Tots)
- 11. 11
- 12. 12 Interpretation For this secondary outcome, we found no evidence that just less than 1 h of sevoflurane anaesthesia in infancy increases the risk of adverse neurodevelopmental outcome at 2 years of age compared with awake-regional anaesthesia.
- 14. Rigshospitalet The Safe Anesthesia For Every Tot (Safetots) Initiative SAFETOTS Torsten Lauritsen 14
- 15. Rigshospitalet The 5 W’s SAFETOTS Torsten Lauritsen 15 • Who • Where • What • When • How ANESTHESIA SHOULD BE PROVIDED IN CHILDREN
- 16. Rigshospitalet Who – Paediatric anaesthesiologists SAFETOTS Torsten Lauritsen 16 • Case load of 2-300 < 10 y, at least 1 neonate/month • Trained paediatric anaesthesiologist • Formal educational programs • Supervision of residents or fellows 1:1 Complications: 1 to 100 cases: 7.0 +/- 24.8 per 1000 anesthetics 100 to 200 pediatric anesthetics 2.8 +/- 10.1 per 1000 anesthetics > 200 pediatric anesthetics/year 1.3 +/- 4.3 per 1000 anesthetics Relationship Between Complications of Pediatric Anesthesia and Volume of Pediatric Anesthetics Auroy, Yves MD; Ecoffey, Claude MD; Messiah, Antoine MD; Rouvier, Bernard MD Anesthesia & Analgesia: January 1997 - Volume 84 - Issue 1 - pp 234-235
- 17. Rigshospitalet More complications in paediatric anaesthesia 17 Nunnally et al Anest-analg 2015, 120(2)
- 18. Rigshospitalet APRICOT data SAFETOTS Torsten Lauritsen 18
- 19. Rigshospitalet Number of fellows SAFETOTS Torsten Lauritsen 19 0 5 10 15 20 25 30 35 2003 2004 2005 2006 2007 2008 2009 2010 2011 2013 2015 2017
- 20. Rigshospitalet Developing Paediatric Anaesthesia SAFETOTS Torsten Lauritsen 20
- 21. Rigshospitalet Where SAFETOTS Torsten Lauritsen 21 • Specialized paediatric centres with dedicated paediatric anaesthesia teams • Centralization for infants and neonates • 24/7 service • Centres with minimum 1000-1500 cases pr year • Backup functions – PICU, pain service
- 22. Rigshospitalet What SAFETOTS Torsten Lauritsen 22 • Specialized procedures in specialized centres • General procedures on older children in regional centres
- 23. Rigshospitalet When SAFETOTS Torsten Lauritsen 23 • Timing of procedures in relation to age and comorbidities • Delay can however result in serious complications
- 24. Rigshospitalet How SAFETOTS Torsten Lauritsen 24 • The right anaesthesia • For the right patient • At the right time • By the right anaesthesia team
- 25. Rigshospitalet The 10 N’s SAFETOTS Torsten Lauritsen 26 •No fear •No pain •Normothermia •Normoglycemia •Normonatremia •Normovolemia •Normotension •Normooxemia •Normal heart rate •Normocarbia
- 26. Rigshospitalet No fear – does it affect the child to sense fear SAFETOTS Torsten Lauritsen 27 • Physically restraining a child is more painfull than the procedure itself • Impaired developement of speech • Needle phobia in adulthood Czarnecki ML, Turner HN, Collins PM, Doellman D, Wrona S, Reynolds J. Procedural pain Management: a position statement with clinical practice recommendations. Pain Manag Nurs. 2011 Jun
- 27. Rigshospitalet SAFETOTS Torsten Lauritsen 28 Worst pain intensity in the past 24 hours
- 28. Rigshospitalet SAFETOTS Torsten Lauritsen 30 The effect of painfull stimuli • Neonate – longterm changes in pain sensitivity and CNS development • Difficulties with procedures in the future • 25 % of adults in the USA with needle phobia Taddio A, Chambers CT, Halperin SA, et al . Inadequate pain management during childhood immunizations: the nerve of it. Clin Ther2009;31(Suppl 2):S152–67.
- 30. Rigshospitalet Tracey et al. Imaging attentional modulation of pain the periaqueductal gray in humans. J Neuroscience 2002 •Pain activates • Sensory cortex • Limic areas (emotions) • Associative (processing) • Motoric areas •Pain processing networks • Periaqueductal gray areas •Distraction increases the activity in the PAG Distraction
- 31. Rigshospitalet Normovolemia Normotension Normal heart rate Normocarbia Normooxemia SAFETOTS Torsten Lauritsen 34
- 32. Rigshospitalet Cerebral perfusion SAFETOTS Torsten Lauritsen 35 Parameters affecting cerebral perfusion Arterial blood pressure Oxygen content (inspired fraction, alveolar, blood) Carbon dioxide (partial pressure of cerebral blood) Plasma glucose Body temperature
- 33. Rigshospitalet What is the correct blood pressure in a neonate of 32+4 undergoing general anaesthesia? SAFETOTS Torsten Lauritsen 36 • Systolic BP > 45 • Systolic BP > 49 • Mean BP > 30 • Mean BP > 32 • Systolic BP more than 80% of baseline
- 34. Rigshospitalet Blood pressure SAFETOTS Torsten Lauritsen 37 • Use correct cuff size – too small => over estimation • Non-invasive = oscillometric = measurement of MAP • We measure pressure – not flow – what is the right pressure? • Differences between arms and legs • Hypotension = MAP < 5-10th percentile • Premature: MAP > Gestational age (weeks) • Cerebral autoregulation is important for cerebral protection • Lower limit at the definition of hypotension
- 36. Rigshospitalet Vital signs change during anaesthesia in neonates SAFETOTS Torsten Lauritsen 39
- 37. Rigshospitalet 36 w Gastroschises – Primary surgery SAFETOTS Torsten Lauritsen 40
- 38. Rigshospitalet 36 w, re-operation for suspected GI perforation SAFETOTS Torsten Lauritsen 41
- 39. Rigshospitalet Hypocapnia SAFETOTS Torsten Lauritsen 42 • Hypercapnia => Cerebral vasodilatation • Hypocapnia => Cerebral vasoconstriction Neonatal brain damage related to hypocapnia Watershed lesions Pontosubicular necrosis Multicystic encehalomalacia Cystic periventricular leukomalacia Reactive hyperemia and hemorhage
- 40. 44 Glucose Temperature pH Electrolytes Sedation Cerebral perfusion Chalkias A in J of Neurological Sciences 2012 Neuroprotective agents
- 41. Rigshospitalet Normooxemia SAFETOTS Torsten Lauritsen 45 Fetal oxygen saturation Fauchere et al J Ped 2010
- 42. Rigshospitalet Hyperoxia is difficult to detect SAFETOTS Torsten Lauritsen 46
- 43. Mortality risk lowest at O2 8 – 10 kPa (60 – 75 mmHg) Mortality risk increase with hypoxia and hyperoxia OR 1,92 OR 1,25
- 45. Rigshospitalet Maintenance of body homeostasis SAFETOTS Torsten Lauritsen 50 • Temperature • Normovolemia • Avoid hypotonic fluids • Normonatremic • Avoid hyponatremia • Normoglycemia
- 47. Rigshospitalet What to tell the parents SAFETOTS Torsten Lauritsen 52 http://safetots.org/what%20to%20tell%20the%20parents.htm
- 49. Rigshospitalet Take home message SAFETOTS Torsten Lauritsen 54 •Well known risk factors have to be in focus •Safe conduct of anaesthesia in young children has to be in focus •Developing guidance on quality markers in paediatric anaesthesia •Implementation of national regulations of WHO, WHERE, WHAT, WHEN and HOW
Editor's Notes
- Children < 60 w, hernia repair, Awake regional or GA with sevoflurane. 363 Reg and 359 GA
- A significantly (P < 0.05) higher incidence of complications was found in the groups that performed 1 to 100 (7.0 +/- 24.8 per 1000 anesthetics) and 100 to 200 pediatric anesthetics (2.8 +/- 10.1 per 1000 anesthetics) than in the group that administered more than 200 pediatric anesthetics/year (1.3 +/- 4.3 per 1000 anesthetics).
- Findings Between April 1, 2014, and Jan 31, 2015, 31 127 anaesthetic procedures in 30 874 children with a mean age of 6·35 years (SD 4·50) were included. The incidence of perioperative severe critical events was 5·2% (95% CI 5·0–5·5) with an incidence of respiratory critical events of 3·1% (2·9–3·3). Cardiovascular instability occurred in 1·9% (1·7–2·1), with an immediate poor outcome in 5·4% (3·7–7·5) of these cases. The all-cause 30-day in-hospital mortality rate was 10 in 10 000. This was independent of type of anaesthesia. Age (relative risk 0·88, 95% CI 0·86–0·90; p<0·0001), medical history, and physical condition (1·60, 1·40–1·82; p<0·0001) were the major risk factors for a serious critical event. Multivariate analysis revealed evidence for the beneficial effect of years of experience of the most senior anaesthesia team member (0·99, 0·981–0·997; p<0·0048 for respiratory critical events, and 0·98, 0·97–0·99; p=0·0039 for cardiovascular critical events), rather than the type of health institution or providers. Interpretation This study highlights a relatively high rate of severe critical events during the anaesthesia management of children for surgical or diagnostic procedures in Europe, and a large variability in the practice of paediatric anaesthesia. These findings are substantial enough to warrant attention from national, regional, and specialist societies to target education of anaesthesiologists and their teams and implement strategies for quality improvement in paediatric anaesthesia.
- highly significant association between MAP ,30 mm Hg and intraventricular haemorrhage in infants born at 26–30 weeks gestation.61 The consensus statement of the Joint Working Group of the British Association of Perinatal Medicine recommends that the MAP not be allowed to decrease below the infant’s gestational age in weeks.62 However, there is also evidence that correction of hypotension with vasopressors or plasma expanders can actually increase the incidence of adverse neurological events.63–65 The acceptable arterial pressure for an individual undergoing anaesthesia is generally less than his or her baseline arterial pressure. The definition of hypotension under anaesthesia is a MAP of 20% less than baseline.66 A recent survey of members from the Society of Pediatric Anesthesia and the Association of Paediatric Anaesthetists designated an acceptable systolic threshold for neonates as 45.5 (8.5) and 49.6 (8.4) mm Hg, respectively, for the two societies. As for a qualitative definition, a change from systolic arterial pressure baseline of 20–30% was indicative of intraoperative hypotension for 70% of the responders, a decrease of 40% for 6%.67 Other investigators have sought to define hyp
- BACKGROUND: The General Anesthesia compared to Spinal anesthesia (GAS) study is a prospective randomized, controlled, multisite, trial designed to assess the influence of general anesthesia (GA) on neurodevelopment at 5 years of age. A secondary aim obtained from the blood pressure data of the GAS trial is to compare rates of intraoperative hypotension after anesthesia and to identify risk factors for intraoperative hypotension. METHODS: A total of 722 infants ≤60 weeks postmenstrual age undergoing inguinal herniorrhaphy were randomized to either bupivacaine regional anesthesia (RA) or sevoflurane GA. Exclusion criteria included risk factors for adverse neurodevelopmental outcome and infants born at <26 weeks of gestation. Moderate hypotension was defined as mean arterial pressure measurement of <35 mm Hg. Any hypotension was defined as mean arterial pressure of <45 mm Hg. Epochs were defined as 5-minute measurement periods. The primary outcome was any measured hypotension <35 mm Hg from start of anesthesia to leaving the operating room. This analysis is reported primarily as intention to treat (ITT) and secondarily as per protocol. RESULTS: The relative risk of GA compared with RA predicting any measured hypotension of <35 mm Hg from the start of anesthesia to leaving the operating room was 2.8 (confidence interval [CI], 2.0–4.1; P < .001) by ITT analysis and 4.5 (CI, 2.7–7.4, P < .001) as per protocol analysis. In the GA group, 87% and 49%, and in the RA group, 41% and 16%, exhibited any or moderate hypotension by ITT, respectively. In multivariable modeling, group assignment (GA versus RA), weight at the time of surgery, and minimal intraoperative temperature were risk factors for hypotension. Interventions for hypotension occurred more commonly in the GA group compared with the RA group (relative risk, 2.8, 95% CI, 1.7–4.4 by ITT). CONCLUSIONS: RA reduces the incidence of hypotension and the chance of intervention to treat it compared with sevoflurane anesthesia in young infants undergoing inguinal hernia repair. (Anesth Analg 2017;125:837–45)
- Only 11/435 had no deviations Background: Commonly used general anesthetics are considered to be neurotoxic to the developing rodent brain, leading to poor long-term outcome. However, it is unclear whether these rodent studies can be extrapolated to the human neonate. Given that anesthesia for urgent neonatal surgery cannot be avoided, it is vitally important to assess other factors that may impact neurological outcome following anesthesia and surgery. Objective: The purpose of this study is to identify thresholds for detecting vital sign deviations, which may have the potential for affecting neurological outcome following anesthesia and surgery in neonates. These data may be suitable to identify targets for prospective quality improvement projects and guide future research for strategies to reduce detrimental neurocognitive outcomes. Methods: A retrospective analysis of vital sign data was performed for neonates (age ≤28 days), undergoing noncardiac surgery over a 4-year period (2010–2013). Thresholds for detecting bradycardia, tachycardia, hypothermia, hyperthermia, hypertension, hypotension, hypocarbia, hypoxemia, significant changes in mean arterial blood pressure, and periods of high inspired oxygen concentration, were proposed. Selected chart review, to identify additional risk factors, and identify sources of data artifact, was performed for 224 cases. Results: Data from 435 procedures in neonates, with median (IQR [range]) ages of 6 (2–16 [0–28]) days were available for analysis. Five (3–6 [0–12]) rule deviations per case were observed; only 11 cases had no rule deviations. Hypothermia was observed in 285/435 (70%), moderate hypocapnia in 298/ 430 (69%), and severe hypotension in 270/435 (62%) cases. Conclusion: An objective method of comparing cases has been created with a method to automatically identify neonatal vital sign deviations. With further validation the method has the potential to be a powerful tool to drive future quality improvement projects in neonatal anesthesia. © 2016 John Wiley & Sons Ltd Pediatric Anesthesia 26 (2016) 1071–1081 1071
- Both Extremes of Arterial Carbon Dioxide Pressure and the Magnitude of Fluctuations in Arterial Carbon Dioxide Pressure Are Associated With Severe Intraventricular Hemorrhage in Preterm Infants Jorge Fabres, MD, MSPHa, Waldemar A. Carlo, MDa, Vivien Phillips, RNa, George Howard, DrPHb, Namasivayam Ambalavanan, MDaOBJECTIVE. The goal was to test the hypothesis that extremes of PaCO2 during the first 4 days after birth are associated with severe intraventricular hemorrhage (grades 3 and 4). METHODS.A single-center retrospective review of clinical and blood gas data in the first 4 postnatal days for 849 infants with birth weights of 401 to 1250 g was performed. The univariate and multivariate relationships of severe intraventricular hemorrhage with maximal and minimal PaCO2, PaCO2 averaged over time (timeweighted PaCO2), and measures of PaCO2 fluctuation (SD of PaCO2 and difference in PaCO2 [maximum minus minimum]) were assessed. RESULTS. Birth weight (mean SD) was 848 212 g, and the median gestational age was 26 weeks. Infants with severe intraventricular hemorrhage had higher maximal PaCO2 (median: 72 vs 59 mm Hg) and time-weighted PaCO2 (mean: 49 vs 47 mmHg) values but lower minimal PaCO2 values (32 vs 37mmHg). High PaCO2, low PaCO2, SD of PaCO2, and difference in PaCO2 predicted severe intraventricular hemorrhage, but time-weighted average PaCO2 was not as predictive. CONCLUSIONS. Both extremes and fluctuations of PaCO2 are associated with severe intraventricular hemorrhage. It may be prudent to avoid extreme hypocapnia and hypercapnia during the period of risk for intraventricular hemorrhage.
- Post cardiac arrest syndrome Brain injury is the cause of death in 68 % of out of hospital CA and 23 % of in-hospital CA
- We conducted a retrospective cohort study using the Pediatric Intensive Care Audit Network (PICANet) database between 2003 and 2010 (n122 521). Patients aged 16 years with documented cardiac arrest preceding PICU admission and arterial blood gas analysis taken within 1 hour of PICU admission were included. The primary outcome measure was death within the PICU. The relationship between postarrest oxygen status and outcome was modeled with logistic regression, with nonlinearities explored via multivariable fractional polynomials. Covariates included age, sex, ethnicity, congenital heart disease, out-of-hospital arrest, year, Pediatric Index of Mortality-2 (PIM2) mortality risk, and organ supportive therapies. Of 1875 patients, 735 (39%) died in PICU. Based on the first arterial gas, 207 patients (11%) had hyperoxia (PaO2 300 mm Hg) and 448 (24%) had hypoxia (PaO2 60 mm Hg). We found a significant nonlinear relationship between PaO2 and PICU mortality. After covariate adjustment, risk of death increased sharply with increasing hypoxia (odds ratio, 1.92; 95% confidence interval, 1.80 –2.21 at PaO2 of 23 mm Hg). There was also an association with increasing hyperoxia, although not as dramatic as that for hypoxia (odds ratio, 1.25; 95% confidence interval, 1.17–1.37 at 600 mm Hg). We observed an increasing mortality risk with advancing age, which was more pronounced in the presence of congenital heart disease. Figure 2. Relationship between PaO2, congenital heart disease, age, and probability of death in the pediatric intensive care unit (PICU) after admission after cardiac arrest. The graphs are constructed to show estimated risk of death for a patient in 2010 with the following attributes: Median Pediatric Index of Mortality-2 (PIM2) risk with oxygenation component removed, female sex, non-Asian ethnicity, outof- hospital arrest, no interhospital transfer, and receiving mechanical ventilation, inotropes, and renal replacement therapy.
- significant at a univariate level (P < 0.0001), but with only the lowest two deciles having ORs significantly greater than the norm (Figure 1). After adjustment for FiO2 and the covariates described in Additional file 1, Statistical appendix, Model cluster 2, PaO2 was no longer predictive of hospital mortality (P = 0.21), although those patients with isolated hypoxemia (PaO2 < 60 mmHg) had a significantly greater risk (OR 1.2 (95% CI, 1.0 to 1.5), P = 0.03) (Figure 1). Importantly, 492 patients (42.1%) with isolated hypoxemia were receiving deliberate decreases of FiO2 to <0.8 at the time of their hypoxemia. There was no statistical evidence that patients with higher PaO2 levels had significantly greater risk of hospital mortality.
- Data with correction of illness severity